Harry William ArndtGeorgia Department of Human Resources
Vital Records Service
PERMIT FOR THE DISPOSITION OF HUMAN REMAINS
(33SZ53
PERMIT NUMBER
Name of Deceased
Date of Death
Fetal Death?
NcXE:l
1. HARRY WILLIAM ARNDT
2: 5/25/1996
3. Yes El
Place of Death (Hospital or Street No.) OR Interment (Cemetery)
City, Town or Location of Death OR Interment
County of Death OR Interment
PIEDMONT HOSPITAL
ATLANTA, GA
FULTON
4.
5.
6.
Name of Certifying Physician, Coroner or Medical Examiner
Certifier's Address (Not Used For Disinterment/Reinterment)
(Not Used For Disinterment/ Reinterment)
105 COLLIER ROAD SUITE
3060
TMICHAEL GOODMAN, MD
8. ATLANTA, GA 30309
Funeral Home Name and Address
Funeral Home Lie. No.
MCKOON FUNERAL HOME, INC.
9.38 JACKSON ST. P.O. BOX 692 NEWNANi
GA 30264
10. 182
Method of Disposition
s
OR
Date of Disposition OR
Reinterment
Disinterment/
11. Cremation ❑ Donation El Other El
Removal From State [3X
Reinterment
12- 5/26/1996
Name and Address of Disposition OR Reinterment Site
Location of Disposition OR Reinterment
Site
(County, City or State)
CAMPBELL—AMAN FUNERAL HOME
13444 SOUTH 17TH ST.
14. BLAIR, NEBRASKA .68008
31-10-20.(a) The funeral -director -or person acting as such, or other person
fetus shall obt3" 'm)a disposition er it prior to cremation or removal from the
may be reqLjre'd ,within the sta e by Ocal authorities.
Local Vital Re/rdsRegistrar Signature
Sexton (or Person In Charge) - Signature
Olt
17.
Form 3934 (Rev. 8-91) FUNERAL DIRECTOR
t assumes custody 01 a dead body or
the body or fetus. A disposition permit
Date Signed
5/25/1996
16.
Date Signed
18.